Research projects

Eating Disorders with Comorbid Depression and Anxiety – Literature Review

Principal Researchers

Dr Sarah Russell

Dr Giuliana Fuscald

Ms Wendy Ealey

Institution

Research Matters

Funding

$15,000

Project completion year

2008

Project brief

The report provides a descriptive summary of key literature on concurrent eating disorders and depression/anxiety, including systematic reviews.

A search of MEDLINE, PsychoINFO and CINAHL databases and Google Scholar identified 6,000 studies on concurrent eating and anxiety or mood disorders published between 2000 and 2008.  The review focused on nine key articles.

Literature was categorised under four headings:

  1. an overview of recent literature reviews of the clinical symptoms of concurrent eating, mood and anxiety disorders
  2. a summary of theories explaining why the disorders might be present simultaneously
  3. a summary of prevalence studies
  4. a summary of reviews of treatment options.

Key findings

The relationship between eating disorders, mood disorders and anxiety disorders is unclear.

Major depression is the most commonly noted psychiatric disorder in women with anorexia nervosa.  Retrospective studies indicate that anorexia nervosa occurs both before depression and vice versa, and several medium and long-term outcome studies suggest depression may persist after recovery from anorexia nervosa.

The presence of anorexia nervosa significantly increases patients’ risk of also experiencing an anxiety disorder.  Anxiety in people with anorexia nervosa most commonly manifests as generalised anxiety disorder, obsessive compulsive disorder or social phobia.  More than half of women with anorexia nervosa also have an anxiety disorder during their lives.

Most studies indicate that the onset of an anxiety disorder usually precedes the onset of anorexia nervosa.

People with bulimia nervosa-associated major depression have different depressive features than those with depression.  Depression can be present before bulimia nervosa and vice versa, and some individuals with bulimia nervosa continue to experience depression after recovering from the eating disorder.  Women with bulimia nervosa and depression respond to antidepressant medication.

The most commonly seen anxiety disorders in women with bulimia nervosa are social phobia and general anxiety disorder.  Studies suggest the presence of lifetime anxiety disorders in more than half of women with bulimia nervosa.  Symptoms of anxiety disorders are usually seen before those of bulimia nervosa.

Treatments for people with an eating disorder and depression and/or anxiety identified in the literature include medication, re-nutrition, cognitive behavioural therapy, family therapy, dialectical behavioural therapy, interpersonal therapy, psychotherapy and self-help.  However, there is limited evidence about their effectiveness.

Implications for policy, practice and further research

The literature provides little guidance on how co-morbidity should be treated in people with eating disorders.  It is not clear whether either the eating disorder or the mood/anxiety disorder should be targeted first or whether the disorders should be treated simultaneously.  Some investigators have suggested that effective treatment should address the underlying cause of the eating disorder.  However, minimal effects of treatment can be expected if the patient is still starved.

Absorption of medication is a major issue, especially among purging patients.  Cognitive therapies may be effective for depression in these patients.  However, there is no evidence to suggest that cognitive behavioural therapy is a superior treatment compared with pharmacological treatments.

Although Eating Disorders Not Otherwise Specified (EDNOS) is the most common category of eating disorder encountered in routine clinical practice, it is largely neglected by researchers.

The literature outlining the effectiveness of treatment for anorexia nervosa, bulimia nervosa and binge eating disorder varies in quality.  In future studies, researchers must ensure reliable statistical power, research design, standardised measures and appropriate statistical methods. 

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